NEW YORK (Reuters Health) - A study of U.S. Medicare claims
finds a jump in extra doctor consultations before cataract
surgery, but no clear medical reason for the added costs.

"The preoperative medical consultation is an understudied
area. It's an intervention that we spend several billion dollars
on each year in this country. We know surprisingly little about
the process," Dr. Stephen Thilen told Reuters Health.

"What we're studying here is how often do we bring a third
provider in - a service that is in addition to the others and
it's separately billed. It adds an expense," said Thilen, an
assistant professor of anesthesiology and pain medicine at the
University of Washington in Seattle who led the study.

A cataract is a medical condition in which the lens of the
eye becomes opaque and causes blurred vision.

Surgery to remove the cataract is generally low-risk, and is
the most common elective surgery performed on beneficiaries of
Medicare, the U.S. health insurance program for people over 65.

Patients awaiting cataract surgery generally see the
ophthalmologist who performs the surgery and the
anesthesiologist or anesthetist if one is needed. Both
consultations are covered by the flat price Medicare pays those
providers for the surgery.

Thilen's team looked at trends in additional preoperative
consultations with the patient's family doctor, cardiologist,
pulmonologist, endocrinologist or other physician not directly
involved in the surgery.

So far, little is known about the value of these extra
consultations when patients are involved in lower-risk
procedures, such as most cataract surgeries, Thilen said.

"There has been more published on high risk patients.
Generally we would expect patients coming for heart surgery,
liver transplants, vascular surgery - those high risk procedures
- we would expect them to often have preoperative medical
consultations because they're high risk patients and they have
many issues that need to be addressed," Thilen said.

No national guidelines indicate whether and when cataract
surgery patients need an additional preoperative consultation,
Thilen and his colleagues write in JAMA Internal Medicine.

So they looked at Medicare billing data for 556,637 patients
who had their first cataract surgeries between 1995 and 2006 and
found that the proportion of patients getting preoperative
medical consultations rose from 11 percent in 1995 to 18 percent
in 2006.

When they analyzed claims for the last two years of that
period, they found the patients most likely to have the extra
consultations tended to be older and also had anesthesiologists
involved in their care. The number of consultations was also
higher in urban areas and they were about three times more
common in the northeastern U.S. compared to the South.

The researchers did not have access to clinical records so
they don't know why any of the consultations were ordered or if
they added any value to patient care.

"We're only in the beginning of this. We hope to contribute
to more cost effective care and peri-operative management. We
will study other procedures, we will look at other types of data
beyond Medicare data," Thilen said.

"Ideally we should have more information on whether these
consultations improve outcomes in one way or another," Thilen
said.

More than two million Medicare beneficiaries have cataract
surgery every year, Thilen and his colleagues note in their
report.

"One approach to improving the value equation is the
elimination of unnecessary or wasteful tests and procedures.
This forms part of the basis of the Choosing Wisely campaign
from the American Board of Internal Medicine," Dr. Lee Fleisher
writes in a commentary accompanying the study.

Fleisher is professor and chair of anesthesiology and
critical care at the Leonard Davis Institute, Perelman School of
Medicine of the University of Pennsylvania in Philadelphia.

"A major theme within the Choosing Wisely campaign has been
the elimination of routine preoperative evaluation in low-risk
patients. Given that 30 million Americans undergo surgery
annually and approximately 60 percent of them undergo a
procedure on an ambulatory basis, the elimination of extensive
preoperative tests and consultations represents an area of
potentially large healthcare savings," he writes.

But Dr. Daniel Albert thinks preoperative consultations are
more common because the standard of care is higher now than in
1995.

The surgeon's reimbursements for cataract surgery are lower
now than in 1995," said Albert, who is founding director of the
University of Wisconsin McPherson Eye Research Institute and a
professor in the Department of Ophthalmology and Visual Sciences
at the University of Wisconsin. He was not involved in the
study.

"The idea that you had to have a more stringent examination
and it had to be done within 30 days of the surgery became more
widespread over the period they're looking at," Albert said.

The type of anesthesia may also have something to do with
when preoperative consultations or done, he told Reuters Health.

Albert said most cataract surgeries performed at his
institution are done with local (or topical) anesthetics with a
'regular' nurse assisting, but some places require monitored
anesthesia - the type that requires the presence of an
anesthesiologist or nurse anesthetist.

He also points out that the data might be outdated, since
the study ended in 2006 and even the surgical procedure has
changed considerably since then.

"It's much quicker now and more technologically driven. It's
much safer and the complication rate is far lower than it was in
1995," he said.

Albert also said that co-management in cataract surgery
usually is between an optometrist and ophthalmologist and
usually the family practitioners or internal medicine physicians
are not involved.

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